Activity of Daily Living and Its Associated Factors in War Survivors with No Visual Acuity

BACKGROUND: War is a known cause of tremendous physical injuries to different body organs, and eyes are not exceptions. War-related no visual acuity (NVA) affects both the victim and the family. Activity of daily living (ADL) can display personal life independency and is considered as a morbidity index. This study was designed to investigate the ADL profile of war survivors with NVA.

ifferent physical injuries -affecting human health -can occur as consequence of war.Loss of visual acuity is by far one of these unwanted consequences of war.Bullets, bursts, burning and chemical agents all can cause severe visual impairment in people participating in wars. 1 Severe visual impairment can heavily affect people and their family.3][4][5] To find out dependency consequences of NVA, some studies has been designed to assess the effects of NVA on ADL, [6][7][8][9][10] which are mostly surveys.
Different measures are used in assessment of being handicap followed by NVA. 4,11,12ADL can be used as a screen test that evaluates some aspects of personal daily life such as clothing and bathing.It can show how much somebody is independent in daily activities.ADL studies can determine people who need more special services to maintain personal independency. 13,14High dependence for ADL can be even a predictor for death. 14,15his study was designed to investigate the ADL profile of people with war related NVA.

Design and Setting
This is a cross sectional study on Iranian people with war related NVA in 2007.Five hun-D dred people with war related NVA were invited by Martyrs Foundation through provincial offices to take part in a camp in Mashhad city.

Participants
Participants included 250 out of 500 survivors with NVA who accepted the invitation and came from all the provinces.There was no special exclusion criterion.The total number of people with war related NVA in Iran is 700.

Data Collection
For the assessment of ADL, we used Barthel index, which is one of the most famous instruments for ADL study.Barthel index evaluates 10 aspects of daily life including feeding (0 = unable, 5 = needs help cutting, spreading butter, etc., or requires modified diet, 10 = independent), bathing (0 = dependent, 5 = independent [or in shower]), grooming (0 = needs to help with personal care, 5 = independent face/hair/teeth/shaving [implements provided]), dressing (0 = dependent, 5 = needs help but can do about half unaided, 10 = independent (including buttons, zips, laces, etc.), bowels (0 = incontinent [or needs to be given enemas], 5 = occasional accident, 10 = continent), bladder (0 = incontinent, or catheterized and unable to manage alone, 5 = occasional accident, 10 = continent), toilet use (0 = dependent, 5 = needs some help, but can do something alone, 10 = independent [on and off, dressing, wiping]), transfers (bed to chair and back) (0 = unable, no sitting balance, 5 = major help (one or two people, physical), can sit, 10 = minor help (verbal or physical), 15 = independent), mobility (on level surfaces) (0 = immobile or < 50 yards, 5 = wheelchair independent, including corners, > 50 yards, 10 = walks with help of one person [verbal or physical] > 50 yards, 15 = independent [but may use any aid; for example a stick] > 50 yards), and stairs (0 = unable, 5 = needs help [verbal, physical, carrying aid], 10 = independent).Total score ranges between 0 and 100. 16emographic data were collected through a data sheet.Data gathering team was trained just before the process in the study field.The mean time for each part of the assessment was about 15 minutes.Every data sheet and questionnaire was checked on the site and data cleaning was done in the field of the study.

Statistical Analysis
Statistical analysis including stepwise regression, independent sample t test, ANOVA, Chi square and Tukey were done by a professional statistician.

Participants
Out of 500 people invited for the event, 250 (50%) agreed to participate.The mean age was 43 ± 8 years.The period of NVA ranged from 1 to 29 years, but 79.2% were afflicted to NVA for more than 20 years.
Among the participants, 96.5% were male, 80.9% were jobless, 94.4% were married, and 31.1% had an undergraduate degree.The main frequent cause of NVA was explosion (98%).Only 18.7% reported their NVA as their single impairments, and others had at least one other co-morbidity.The most common injury was burst hit to face.(Table 1)

Associated Factors of ADL
Independency in ADL was reported by 8.3%, while 91.7% were dependent at least in one daily life activity.Highly educated participants had higher ADL scores (p = 0.012).Number of injuries was associated with ADL (p = 0.034).Age of 50 years was a marginal level for ADL independency decline.Co-morbid injuries significantly declined ADL score.

ADL Regressors
According to the regression analysis, age and duration of NVA were significant predictors of ADL.(Table 2)

Discussion
According to the results of this study, age and the time passed since NVA both increase the dependency of people with war related NVA.The mean age of people in the world has increased within the second half of the 20 th century due to decrease of birth rate and increase of life span, so that the population of people over the age of 65 during 2010 to 2030 would be significantly higher than previous decades.
As the process of ageing continues, most of the fatal factors will change to disability factors.][19] According to the literature, ADL declines following NVA, and some believe that there is no relation between the cause of NVA and lack of health related quality of life (HRQOL) and ADL independency. 20,21VA is a cause of not only morbidity (as presented here), but also mortality.NVA increases the risk of death by 1.4 times, apart from any complication and dependency occurring after NVA.If the functional problems are included in this model, the risk of death for this group will increase 38.1% more than general population.Therefore, prevention is more cost-efficient than service providing, although rehabilitation services can be effective and helpful in current situations.4][25][26] The current study as a crosssectional one can provide a baseline for further studies to plan for the times when there is no reliable or accurate information. 27imilar to other types of NVA, war related NVA is a costly phenomenon.Rehabilitation and care services for one NVA patient may cost annually between 9749 to 26720 dollars. 28ost of all NVA (not only the war related) has been estimated about 4.4 million dollars in India, 29 and 4 billion dollars in the United States. 30ome studies presented other classifications.For example, if there were some problems in mobility, bladder control, bowel and bathing, there would be major difficulties in ADL. 13 A study on Mexican citizens in the United States used the data of 2800 records of an epidemiology assessment of old age and found a significant correlation between ageing and ADL decrease.However, some other factors such as education level, high blood pressure, diabetes mellitus, low self-reported health status, and admission had significantly effects on ADL.Therefore, at least 50% of cases needed help in at least one of the daily activities.But the visually impaired and visually intact people had less dependency and needed less help. 31,32ccording to the results of the current study, 91.3% of the survivors with NVA had some dependency.Ageing decreases ADL.In a study in the United States on people with mean age of 72 years, 32% were dependent for bathing, 37% for clothing, 11% for feeding and toilet use, 10% for bed to chair transfer, 55% for transfer to stairs and 13% for mobility on ground level surfaces.A study conducted by Brench and Horwitz compared two groups of with and without visual impairment old people (over 66 year).They found that visual impairment can reduce ADL and lead to more dependency as compared with those without visual problem, especially in physical and emotional daily living. 31,33cording to this study, the war survivors with NVA face many serious problems in ADL and these problems increase with ageing due to some physical impairments and disabilities.
A study that compared ADL in two groups of physically impaired people with and without visual problems found that visually impaired people had significantly lower ADL scores and a periodic rehabilitation was suggested for them.It shows that rehabilitation is really important to NVA people. 22,31Another study was conducted in a daily clinic on the elderly people with visual impairment and hearing loss to assess their ADL and personal independency.The study had two historical and prospective parts and was conducted in a period of 6 years from 1986 to 1992.According to the results of this study, people with no visual problem had a better score of ADL comparing with visually impaired ones.The result of hearing loss was also the same as visual impairment.Therefore, ADL in visually impaired people and those who had hearing loss was significantly lower than normal population. 15][33][34][35] Old age American veterans (over 65 years old) were dependent in at least one of daily activities. 36Systematic and organized health and rehabilitation services reduced their age related dependency. 37owadays, most of the rehabilitation programs aim to improve functional status. 14Even though, the effectiveness of rehabilitation in people with NVA is less than those with normal visual acuity, it greatly and deeply changes their level of independency, 38,39 and they will have more independency especially in daily living and participation.

Conclusions
To conclude, age and duration of NVA can deteriorate the dependency of people with war related NVA.The researchers hope that this study can be a baseline for ADL studies on war survivors with NVA.The results can yield intervention studies and increase their independency.

Table 2 .
Regressors of activity of daily living in Iranian war related blindness (n = 250)